Background: Reported penicillin allergies are present in 10% of the US population, with higher rates in hospitalized and older patients; rates up to 16% have been found in VA nursing home patients. However, fewer than 10% of patients are found to be truly allergic based on skin testing and most patients can safely receive penicillin. The consequences of being labeled as penicillin allergic include use of broader spectrum antibiotics which can result in more treatment failures, more adverse effects, higher healthcare costs, and increased risk for development of antibiotic resistance. The nursing home population is particularly vulnerable to the effects of potentially inappropriate antibiotic use due to factors including high infection burden and frailty. Recognition of the problem of increasing antibiotic resistance and importance of antimicrobial stewardship as a tool to curb it has heightened awareness of this issue of penicillin mis-labelling both in and outside the VA. While guidelines for evaluating and managing penicillin allergy exist, they have been infrequently applied in practice. This in part due to lack of provider knowledge on how to take an appropriate penicillin, the role of allergy testing, risks of mislabeling and lack of access to specialized allergy testing. Significance/Impact: To address these knowledge gaps, an explicit guideline-based clinical pathway and toolkit were recently developed. These have been effectively and safely applied in selected inpatient and outpatient settings to improve outcomes. However, they have not yet been applied to nursing home populations. Thus, this represents a unique opportunity to apply these tools to improve penicillin antibiotic use and outcomes in this vulnerable population. Innovation: This project will be a pre-implementation pilot of a newly available evidence-based clinical pathway and toolkit designed to improve evaluation and management of penicillin allergy. These were developed and thus far only used in the non-long term care setting. Specific Aims: 1) Identify potential barriers and facilitators to successful implementation of a clinical pathway and toolkit aimed at improving use of penicillin in patients with documented penicillin allergies; 1a) examine clinical staff and local leadership perspectives; 1b) examine patients and family members perspectives. 2) Develop a modified pathway and toolkit for use in Community Living Centers (CLCs). Methodology: This is a 1-year qualitative pilot study based at the Bedford VAMC. The Consolidated Framework for Implementation Research (CFIR), supplemented with the Health Belief model for Aim 1b, will guide our assessment to understand contextual factors that may affect uptake of the intervention. For Aim 1a, we will conduct up to 15-20 in-person semi-structured interviews with CLC providers (nurses, physicians, nurse practitioners, clinical pharmacists) and 4-6 with selected local leadership (chiefs of nursing, geriatrics, and pharmacy, patient safety manager). We will examine factors including perceptions of risk of allergy testing, perceived ability to successfully follow the pathway and tools, and solicit recommendations for pathway and toolkit modifications. For Aim 1b, we will conduct up to 15-20 semi-structured interviews with CLC patients with documented penicillin allergies and CLC residents? family members to assess their knowledge and beliefs including their understanding of allergy mislabeling implications and perceived susceptibility to adverse consequences of the allergy testing strategies. Based on information from Aims 1a and 1b, we will propose changes to the pathway and toolkit. We will establish consensus on proposed changes via input from an expert advisory panel using a 2-round modified Delphi approach. We will then have developed a modified pathway and toolkit for use in CLCs. Aim 1 information will also inform subsequent IIR implementation strategies. Implementation/Next Steps: The modified clinical pathway and toolkit will be implemented at selected CLC sites in a future IIR, with the eventual goal of scaling it up for use across the VA to improve care.